Wednesday, October 31, 2012

Will American Psychiatric Association heed professional consensus?

Twenty years ago, Humbert Humbert went to prison for a series of sexual assaults on his 12-year-old stepdaughter, whom he famously nicknamed "Lolita." Now, as his lengthy prison term draws to a close, Wisconsin is petitioning to have the 60-year-old literature professor indefinitely detained as a Sexually Violent Predator.

The venue for last week's trial of Vladimir Nabokov's fictional protagonist was the annual convention of the American Association of Psychiatry and Law (AAPL) in Montreal. The central question, decided by audience vote, was whether the controversial diagnosis "hebephilia" qualified as a legitimate mental disorder justifying Mr. Humbert's indefinite civil detention.

The rousing theatrical performance featured an all-star cast of attorneys and psychologists, presided over by Toronto Judge Maureen D. Forestell. New Jersey Assistant Attorney General Mark Singer served as prosecutor. His expert witness was prominent psychiatrist Richard Krueger, a member of the paraphilias subworkgroup that has proposed adding "hebephilia" to the next edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5). A hebephilic qualifier would extend pedophilia to men with sexual preferences for children who have entered puberty, such as the fictional Lolita.

Defending Mr. Humbert was preeminent Wisconsin attorney Robert LeBell. His expert was Washington psychologist Richard Wollert, who has published peer-reviewed articles on SVP-related topics and testifies for the defense in civil commitment proceedings. Appearing as the court's expert was prominent Canadian psychiatrist John Bradford, an advisor on paraphilia (or sexual deviance) to the DSM-IV, past president of the AAPL and clinical director of the Sexual Behaviors Clinic in Ottawa.

After a spirited and sometimes heated trial, the 131-member audience was given electronic clickers and voted overwhelmingly -- 82 percent -- against including hebephilia as a diagnosis in the DSM-5, due out in mid-2013. A majority also voted against even including the controversial diagnosis in a DSM-5 appendix as a condition meriting further study.

Third time's the charm?

This marks at least the third time in two years that respected professional bodies have voted against the idea of hebephilia as a new mental disorder. At a 2010 vote in Oslo, Norway, members of the International Association for the Treatment of Sexual Offenders (IATSO) were near-unanimously opposed to the newly proposed sexual paraphilia. U.S. forensic psychiatrists followed suit a month later at the 2010 AAPL conference, overwhelmingly voting against hebephilia as well as two other proposed paraphilias, "paraphilic coercive disorder" (aka rape) and hypersexuality, both since scrapped.

Rind and Yuill said they undertook their extensive review of the historical and cross-cultural evidence after hebephilia proponent Raymond Blanchard (a member of the DSM-5 paraphilias subworkgroup) and his colleagues at Toronto's Centre for Addiction and Mental Health brushed aside numerous published criticisms of the proposed disorder (see Table 1). Building on their earlier research, Rind and Yuill argue that hebephilia -- generally defined as sexual attraction to young pubescents in the age range of 11 to 14 -- is a biologically normal trait found to varying degrees in both human males and our closest mammalian relatives, such as higher apes. They blast hebephilia as a bold example of naked moral values masquerading as science:

"Blanchard et al. … did not invoke comparative evidence…. They did not invoke any evidence…. They declared it a disorder by fiat, bypassing scientific analysis in favor of a pre-given conclusion supportable only because it is, for the current time and place, culturally resonant. Had their pronouncement been the opposite (i.e., hebephilia is functional), their article would never have been accepted in a peer-reviewed journal without massive evidential backing. Strongly resonant opinion can facilely pass through without the kind of scrutiny demanded of non-resonant views."

Why hebephilia still clings to life, despite so much opposition and so little scientific support, is beyond me. It's like an unwanted house guest who just refuses to take the hint and pack his suitcase.

The evidence at trial

In attacking the government's diagnosis of his client, defense attorney LeBell focused on the dearth of empirical studies on the condition, other than by researchers at a single Toronto clinic, and the likelihood of "false positive" diagnoses in legal cases.

The wording of the proposed new diagnosis has been changed again and again over the past couple of years. In its current iteration, pedophiles are defined as those who have "an equal or greater sexual arousal from prepubescent or early pubescent children than from physically mature persons, as manifested by fantasies, urges, or behaviors." (The requirements that the fantasies or urges be "recurrent" or "intense" have been removed, broadening the potential pool of sufferers.) Hebephiles are now defined as those with sexual attractions to "pubescent children" in Stages 2 to 3 of Tanner's pubertal stages (e.g., early development of pubic hair and breasts).

Defense expert Wollert testified that the problem of "false positives" -- people incorrectly identified as having a condition -- was extraordinarily high even in the controlled setting of the research laboratory. This problem would be much more acute in the forensic trenches where the hebephilia diagnosis is being deployed, he testified.

One insurmountable problem would be reliably identifying a sexual abuse victim's Tanner stage of pubertal development. Complicating this issue, testified the court's expert, John Bradford, Tanner Stages are highly variable. Because they reflect hormonal developments rather than specific ages, one could not assume a specific Tanner stage based on the age of a victim. About two years ago, alarming research indicated that girls are entering puberty far earlier than in previous generations; this month, a large study by the American Academy of Pediatrics identified a similar trend in boys.

Wisconsin psychiatrist Lynn Maskel, who organized and moderated the mock trial, labeled hebephilia a "weed diagnosis in the botanical garden of DSM."

"The question is not if sex with pubescent year old girls illegal, or if it is immoral," she told the audience of forensic psychiatrists. "The question to the psychiatric field is: Is it a disorder? And if it is, does this translate, for the expert witness, into a requisite mental disorder found in the specific SVP statute?"

Meanwhile, back in the real courtroom trenches …

In my seminal review, published in 2010 in Behavioral Sciences and the Law, I traced hebephilia's sudden emergence and rapid spread in legal discourse to the advent of Sexually Violent Predator laws, which require that the individual being considered for civil detention have a mental disorder that makes him qualitatively different from the garden-variety offender.

Since that article's publication, the introduction of hebephilia in U.S. courts has continued unabated, despite the lack of an official imprimatur by the American Psychiatric Association. In a string of SVP cases brought under the Adam Walsh Act, federal judges in North Carolina have ruled that the faux diagnosis is not a legitimate basis for civil detention.

As the dissenters conceded, Shannon S. was a "very bad actor" and "the community may well be safer if he is kept behind bars."

"But, they added, "to put him there on the fiction that he has some sort of mental condition other than a tendency to commit the crimes for which he was convicted (and has served his time) is and should be constitutionally unacceptable."

Judge Robert Smith, writing for the minority, labeled as "absurd" the premisethat attraction to adolescent girls is abnormal, as the government's two experts testified: "What is abnormal about appellant, and others who commit statutory rape by having sex with girls below the age of consent, is not that they find the girls attractive, but that they are willing to exploit them for their sexual pleasure -- in other words, they commit statutory rape."

Smith labeled hebephilia and the similarly disputed diagnosis of "paraphilia not otherwise specified" (rape) as "junk science devised for the purpose of locking up dangerous criminals." While such a practice might seem appealing from a public safety viewpoint, it creates "dangers of abuse," he eloquently warned:

"Many sex offenders are, or could reasonably be found to be, dangerous, and in common parlance they all have mental abnormalities: Mentally normal people do not commit sex crimes. Thus, unless 'mental abnormality' is defined with scientific rigor, such statutes could become a license to lock up indefinitely, without invoking the cumbersome procedures of the criminal law, every sex offender a judge or jury thinks likely to offend again. "Some will intuitively respond: Not a bad idea. But it is a very bad idea, because not even a concern for public safety should be allowed to trump certain fundamental rules. Among them are that criminals can be confined only for crimes they have committed, after their guilt is proved beyond a reasonable doubt in a procedure in which they receive the many protections that our Constitution gives to those accused of crime, and that even when convicted they can be incarcerated for no more than the term of the maximum sentence provided by law. If the present sentences for sex offenders are too short, the Legislature should make them longer, but it should not, and constitutionally cannot, simply substitute civil for criminal proceedings as a means of keeping dangerous criminals off the streets."

As Judge Smith seems to recognize, it's a slippery slope. Bogus psychiatric diagnoses for sex offenders now, political dissidents (or others) tomorrow. That's the way they rolled in the former Soviet Union, after all.

Pretextual court rulings aside, the paraphilias subworkgroup has had more than two years to produce evidence for the reliability and validity of hebephilia, and it has not done so.

It is clear to most observers that hebephilia is not accepted by the relevant professional community. What remains unclear is whether the Board of Trustees of the American Psychiatric Association will get the message in time to prevent yet another in a veritable maelstrom of public-relations disasters and historical mistakes.

13 comments:

Where is the talk about cultural differences in the world related to what is considered "normal" sexual behavior? This seems to be very influenced by existing laws in the U.S. regarding appropriate sexual activity for minors/adults. I doubt all countries/cultures share the same views or have the same laws about this issue. There is such a big emphasis on being "culturally competent" as a clinician, but culture seems to not be a factor in this proposed diagnosis.

4nSick: That was one of the arguments made by the defense witness in the Lolita case. He pointed to the varying age-of-consent laws around the world as evidence that cultures vary regarding when young people may be considered sexually autonomous.

Cavall de Quer: That gets to your point, too. I don't know about what sex lives they are "supposed to" be having, but we do know that many young people are sexually active, although that seems to be on a downward trajectory these days. (See, for example: http://www.advocatesforyouth.org/publications/413?task=view.)

Doesn't the word "pubescents" sound like some kind of insects being studied under a microscope?

First: I would like to say as always Karen "your webpage is one of the very best sites on the internet" when it comes to talking the truth and real facts relating to this field of study and all the great posts and expert blogs and advice is beyound compare.

I have just one statement to make today and just one question.1.Statement; Has anyone seen what an 11 to 14 year old is wearing along with make-up, hair, perfume etc. these days? along with the language coming out of their mouths,the words in their music and their sexual attitudes?. Their clothing,make-up perfume,music,and sexual attitudes WAS and IS (like it or not) ment to be sexualy alluring.And just as my generation (babyboomers)knew more in the way of sex than my parents did, as they did more than theirs it seems very normal indeed that an adult person just might become sexualy aroused by a 11 to 14 year old. So to say that an adult person who is sexually allured by an 11 to 14 year old (has a mental illness (HEBEPHILIA) better get their heads out of the sand and smell the roses as they say, No it is not using ones better and good judgment(sorry to say it) but some persons just don't have good judgement but that is NOT a mental illness the last time I checked (but I suspect that might be the next to come).

2.question; The sexual offender tests and exams such as static 99 that are used as a tool in civil commentment cases of sexual violent predators (SVP)to confirm if an individual is likley to repeat or commit a violent sex crime in the future are good and work this week but bad and don't work next week and this has been going like this for a time now. But my question is? Am I correct in my interpratation and understanding though that all the experts do seem to admit that they (the tests and the exams) are very good indeed in showing and confirming thoes individuals who are what is termed as being a low threat low level sex offender (the persons less likely to committ another unlawful sexual act) Being the experts seem to be saying lately (again if im correct in my understanding)that thay do need to weed out the low threat lower level offenders firt and this is needed as to allow for getting a better hold of the needed research that is used for these test and exams to be properly interpid by the test examiners ("DO THE TESTS AND EXAMS SHOW WHO IS A LOW LEVEL LOW THREAT OFFENDER? YES OR NO".

I find this entire mock trial interesting, and the outcome is reassuring.

What I want to know is: What is the purpose behind it? I see two already: (1) Providing and/or reinforcing known information on the subject within the psychiatric and legal communities, and (2) bringing about a discussion that might spur additional insight. How would this serve to education society at large at a time when many people are in a state of "hysterics" and unlikely want to hear any of it? Is this somehow an early stage in an overall plan to change the way the legal system deals with such cases?

"The question is not if sex with pubescent year old girls [are] illegal, or if it is immoral," she told the audience of forensic psychiatrists. "The question to the psychiatric field is: Is it a disorder? And if it is, does this translate, for the expert witness, into a requisite mental disorder found in the specific SVP statute?"

This statement appears as the main premise to the mock trial and perhaps the article as well, which suggests that the results serve not necessary to initiate changes in the legal arena as much as the psychiatric community and how it distinguishes mental disorders from non-disorders.

I am all for that, but I find this effort would be difficult (if not impossible) in a field where the definition of 'mental disorder' isn't even clearly established. The debate on that continues between members of the psychiatric community and is misinterpreted by many people outside that field, especially in the legal system (e.g. the reference to the word 'children' in the definition of 'pedophilia'. Legal definitions generate ongoing confusion, and many legal experts want adolescents placed within that definition as well). Shouldn't this distinction be established first?

As for how we presently and historically conceive the notion of 'mental disorder,' attraction to others who are sexually mature (or capable of coitus) despite age, is not abnormal or deviant sexually. That's natural.

Again, what determines the scientific criteria of 'disorder'? The terms within that definition seem to be changing all the time, due to vagueness or ambiguity (as seen through conflicting interpretations).

Sorry . . . I realize I am rambling and everything in my post is old news. I am merely curious as to Maskel's overall agenda with the mock trial. The event must have some kind of objective beyond itself. In any case, I will wait to see where this goes. The particular results, whatever they might be, will not come about over night.

As for the term 'pubescent' being relative to a studied insect, apparently 'hebephilia' is another one, and one that is under even more scrutiny. The nature of both terms are in constant debate.

"That was one of the arguments made by the defense witness in the Lolita case. He pointed to the varying age-of-consent laws around the world as evidence that cultures vary regarding when young people may be considered sexually autonomous."

Yes, but in the context of older adults like Humbert Humbert that might be a different case altogether. Some (not all) European legal statues clarify a CIA ("close in age") exemption with a minimal age that differs from the official AoC. Are the official AoCs in Europe exclusive to those, say, under 18, or do they apply to anyone of any age--even that of Humbert's--over the official AoC? For example: What would happen to Humbert in Germany if Lolita had been aged 14 at the time of the interaction? In Italy where the AoC is 14? In Spain if Lolita had been 13?

If the AoCs in Europe only apply to those individuals CIA and under 18, the cultural argument might be moot in the context of this mock trial. From what I have read, Poland might commit him, considering Lolita's age fell beneath 15 (the AoC in Poland), as the Polish legal system is seriously abhorrent to the idea of sex between an adult and anyone under age 15. Or am I missing something?

" hebephilia -- generally defined as sexual attraction to young pubescents in the age range of 11 to 14 -- is a biologically normal trait found to varying degrees in both human males and our closest mammalian relatives, such as higher apes. "

OK, I understand this but, 1) is it a ' biologically normal trait' and so not a disorder even when a man is exclusively and solely interested in partners in this age range? 2) is there any difference in homosexual and heterosexual relationships? I mean that a heterosexual relationship is linked to the biology of the reproduction but in the homosexual one there is not this element.

"OK, I understand this but, 1) is it a ' biologically normal trait' and so not a disorder even when a man is exclusively and solely interested in partners in this age range?"

I presume by this question that you believe it is? Otherwise, why ask it?

How can an attraction that is not pathological in the first place suddenly become so when exclusive? Would a man with, say, a preference only for redheaded women between 25-and 30 have a pathological attraction? How about one only for heavyset women?

And please don't say there's a difference. The only difference between these two attractions is that one is illegal in various regions while the other is not. Again, law and morality are not [necessarily] correlative to nature and/or science. That is the entire point being made here, and why an attraction for adolescents is not considered pathological by the psychiatric community in the first place.

@ researcheroneOK, as far as I know sex with young pubescents in the age range of 11 to 14 is prohibited in all the Western nations. If there is someone exclusively and solely interested in partners in this age range I suppose that he will have a life full of problems. How psychiatric community addresses this issue?

Rind and Yuill writes that this attraction is "a biologically normal trait found to varying degrees in both human males and our closest mammalian relative"; as they writes about 'human males' have I to suppose that it is not a biologically normal trait in human females?

"If there is someone exclusively and solely interested in partners in this age range I suppose that he will have a life full of problems."

In those regions, yes. No argument from me on that. That would be a criminal issue if said person were to act on that interest, not necessarily a psychiatric one.

"How psychiatric community addresses this issue?"

Experts in this field shouldn't need to address it, actually. They only do so in the context of forensics in relation to criminal cases where a profile is necessary to establish. As said, acting on an interest if it is illegal would be criminal, not psychological or psychiatric. However, in many cases, other issues come into play, such as social ineptitude, but that doesn't necessarily equate to a mental or sexual aberration or abnormality. Social problems may correlate to a personality disorder, but, again, this doesn't mean the attraction itself is abnormal. Experts in the field must determine what is going on with an individual, if anything is at all beyond the mere attraction, and then address that.

Again, people have a hard time separating what is illegal from that which is pathological. These two are not one and the same. The reason why sexual intercourse between an adult and a minor is illegal deals with moral and social makeup, not nature or science. Some very good reasons exist to substantiate why such an interaction should not be acceptable, but these reasons do not negate natural inclinations or the scientific premises/principles that reflect them.

"I [have] to suppose that it is not a biologically normal trait in human females?"

I wouldn't necessarily say that. Apparently both are. Males are dominant in count over females here because they are evolutionarily wired to seek out young fertility or at least to respond to it. They always have. Women do as well. My only explanation for the distinction is that the impulse is stronger in males than in females for the reason(s) given. Men are supposed to be the pursuers and spread their seed, so the impulse is arguably genetic. This might also be why such a condition does not have a "cure." In short: It is not a disease or abnormality that experts can treat.

Karen, what is your take on the theory of genetics? I haven't read anything directly related to it, but a large body of the literature and insight from experts in the field would seem to suggest a genetic connection. I would be interested in reading what you have to say about that. Thanks.

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Karen Franklin, Ph.D. is a forensic psychologist and adjunct professor at Alliant University in Northern California. She is a former criminal investigator and legal affairs reporter. This blog features news and commentary pertaining to forensic psychology, criminology, and psychology-law. If you find it useful, you may subscribe to the newsletter (above). See Dr. Franklin's website for more information.

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